3rd April Pearls and Pitfalls of Dermatology

Transcription

1 3rd April 2014 Pearls and Pitfalls of Dermatology

2 The Basics AVOID SOAP Use Aqueous cream as a soap substitute, i.e. apply before bath/ shower and rinse off Bath oils Oilatum/Balneum LIBERAL EMOLLIENTS 500g tubs, Diprobase/Doublebase/E45 Epaderm/Hydromol/Emulsifying ointment 50:50 WSP:LP

3 Topical Steroids Ointments better than creams unless weeping Choose appropriate strength for condition and site Most patients have fear of steroids and under use but must warn them that steroids are not for continuous use

4 Dermovate ointment Betnovate Ointment Elocon ointment Betnovate RD ointment 1% Eumovate ointment Hydrocor*sone

5 The Pulse Used to get rapid control of inflammatory conditions e.g. eczema Think longer and stronger e.g. 3 weeks daily The taper cut down the potent steroids and alternate with weaker or alternatives The maintenance the twice weekly

6 3rd April 2014 Pitfall The localised eczema Localised eczema Confined to an area Resistant to treatment Recurs in same area May worsen on each reexposure Consider a contact allergen Hair dye PPD allergy Sofa dermatitis Dimethylfumarate Methylisothiazolinone Metals, Fragrance, Rubber

7 Pearl Auto-sensitisation Eczema may start in localised area Becomes widespread Rest of body comes up in sympathy Focus on underlying cause for long term success If leg (common site) address oedema Consider compression Leg elevation ABPI >0.8

8 Pitfall the spreading rash Unilateral rash Itchy Red Dry/Scaly Topical steroid helps symptoms and lessen redness and get rid of scale May have pustules Rash is spreading Tinea Incognito

9 Pearls and Pitfalls Patchy hair loss with broken hairs +/- pustules Page Title Etiam gravida tincidunt mollis. Fusce quam diam, tincidunt sed eleifend sit amet.

10 Pearls and Pitfalls Patchy hair loss with broken hairs +/- pustules

11 Tinea Capitis High incidence in urban environments Always suspect in setting of localised hair loss Low threshold for taking skin scrape or brushings and don t forget family members Treatment 4/52 Terbinafine systemically

12 The Scaly Scalp

13 Pearls - Seborrhoeic Dermatitis Manage Expectations! Regular anti-fungal shampoo ketoconazole, twice weekly + /- Selsun Ketoconazole cream, Daktocort, Tacrolimus/ Pimecrolimus Treatment 4/52 Terbinafine or Pulsed Itraconazole (1 week per month) systemically

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15 Non- Scarring Follicular openings s*ll present, with or without a hair shad Hairs may be smaller (Vellus) or non- pigmented NON SCARRING Varia*on of hair follicle diameter SCARRING Scarring Shiny Absent follicular openings May have surrounding redness or scale Hair shads may be tuded and grouped together

16 Pearls Scalp Psoriasis Hair makes topical treatments physically more difficult Hair has important cosmetic function, and messy treatments and treatments with odour are unacceptable Hair causes retention of scale, allowing it to build up and act as a barrier preventing absorption of topical treatments Hair protects from useful exposure to UV light

17 Condi*oning Treatments Descaling Treatments Ac*ve Treatment

18 Pearls Scalp Psoriasis Conditioning treatments Need to be used regularly as part of on going treatment Aim is to hydrate the scalp epidermis, and soften scale and facilitate it s removal Coal tar based (Polytar, T Gel, alphosyl 2 in1) Antidandruff shampoos (Head and Shoulders, Nizoral, Meted etc) Olive oil, Arachis oil, Epaderm

19 Scalp Psoriasis - Treatments Targeting Scale: Salicylic acid Glycolic acid Zinc Coal tar Sulphur Common Ingredients in shampoos, but need to stay on for minutes, most get washed down the drain! Combinations: Sebco / Cocois (Coal tar, salicylic acid, sulphur) Physical removal of scale with combing

20 Scalp Psoriasis - Treatments Active Treatment Steroids Lotions Mousse Gels Short contact shampoos Ointments/Creams too messy Vit D Calcipitriol Combinations Etrivex Clarelux Dovobet gel Salicylic acid and betamethasone diproprionate (diprosalic) Calcipitriol and Betamethasone (ie like dovobet)

21 Pearls Scalp Psoriasis Take home messages The active treatments will not work unless scale has been removed The conditioning treatments will not work on their own Combination approach is required Control not cure

22 Guttate Psoriasis Typically acute widespread and may follow sore throat Pitfall: If palmer plantar macules consider secondary syphilis If large patch first may be atypical pityriasis rosea Pearl: Coal tar lotion, followed 30 mins by emollients Phototherapy and Ciclosporin very effective

23 Palmar plantar pustulosis Pitfall: If unilateral suspect fungus Pearl: Need super-potent steroids e.g. clobetasol Wrap feet in clingfilm after application

24 Onychomycosis vs Psoriasis

25 Oncyhomycosis vs Psoriasis Pearls: Toes > Fingers Isolated nails rather than all Discoloured and thickened Crumbly debris underneath nail plate Pearls: Nails Pits & Onycholysis commonest signs Subungual hyperkeratosis Trial of diprosalic ointment around nail folds and distal nail plate daily for 3 months

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27 3rd April 2014 Pearl The itchy patient No rash Scars = Chronic Linear = scratch Round = picked Is skin dry? > Urea based emollients Hb, Ferritin, TFTs, U&Es, LFTs, ESR/CRP Any new drugs? > Trial off 3/12 Tetracycline antibiotics Phototherapy

28 3rd April 2014 Pitfall The itchy patient with a rash

29 3rd April 2014 Pearls and Pitfalls Page Title Papule on the penis = Scabies Web spaces, axillae, flanks Look for the trail of scale Can see triangular head with dermatoscope

30 3rd April 2014 Scabies The pitfall Was it scabies? Was treatment done properly? Post scabies itch is very common Resistance is possible but avoid endless retreating with topicals Ivermectin is an option

31 3rd April 2014 Pearls and Pitfalls Non-Healing Ulcer Pitfall Neoplastic ulcer Most commonly BCC Bowen s occasionally will ulcerate SCC is usually the main differen*al Pitfall Pyoderma Inflammatory ulcer Assoc inflammatory bowel disease, Rh A, Rolled purple edge Painful

32 Odd location in young patient take a travel history

33 4th April 2014 Pearl The Pinch

34 Pitfall 4 Widespread AKs very common Flat ones of little concern Can come and go Small Potential to change Beware of the thickened lesion Thickened AKs are persistent and more likely to represent Squamous change

35 AK New treatments

36 AKs Topical treatments Solaraze still commonest prescribed in primary care least inflammatory Efudix Commonest in secondary care Consider twice daily to non-face sites Imiquimod alternative to efudix Actikerall like efudix + salicylic acid good for thickened lesions Picato the new kid, good for rapid treatment 150 mcg x 3 tubes for face 500 mcg x 2 body

37 Pearl The Black Nail Trauma to the nail is almost never recalled Sudden Uniform Splatter globules No Nail fold involvement Does it involve the lunula? Is there a proximal curve? Cut nail back and see if debris scraped away Can photograph and review 3/12

38 4 th April 2014 Pearl 4 The Black Nail Parallel curve of pigment = haematoma

39 Pearl Lesion helps

40 Pearl Lesion helps

41 Pearl Remove scabs

42 Pearl The vessels and stretch Lesions with blood vessels: Spider naevi Telangiectasia Haemangiomas Intradermal naevus BCCs BCC vessels: Arborising Irregular Angulated Wiggly

43 A Scab with a rolled edge and arborizing vessels = BCC

44 If in doubt photo and see again

45 Thank you Dr Paul Farrant FRCP Consultant Dermatologist Tel Web drpaulfarrant.co.uk